2. and ME!diC8| CEHIEY Department of [Radiology
Please fax this form to HFH Radiology Department at (978) 687-1769.
SPECIAL CONSIDERATIONS: Contrast El Y El N Contrast Allergy El Y D N UREFOHMATS (sagittal/coronal) El 3D
Pregnant El Y El N El Unknown BUN/Creat (If El Radiation Planning El Stereotactic
SIGNS AND SYMPTOMS sums AND SYMPTOMS
El Coma (780.01) El Abnormal Extremity Reflexes (796.1) El Convulsions (780.39) El Abnormal Extremity Sensations
(782.0) El Coordination Changes (781.3) E1 Back Pain (724.5)
El Concussion (850.5) Date of Injury Ci Leg Weakness Generalized (780.79)
El Dizziness (780.4) E] Neck Pain (723.1)
El Headache or Face Pain (784.0) El Neurogenic Arm or Shoulder Pain (729.5) El Hearing Changes (389.8) El
Sciatic Leg Pain (729.5) El Hemiparesis (342.90) I] Swelling, Mass or Lump, Spine (239.7) E1 El 823:3: (850 5) Date
of Injury El Cauda Equina Syndrome (344.60) El Pain - Face / Head (784.0) El Disc Herniation Unspecified Site
(722.2) El Speech Changes (784.5) El Fracture Specify Location
El Swelling, Mass, Lump Head/Neck (784.2) E] Infection (type)
El Syncopel Fainting (780.2) D Neoplasm - Specify Primary
U TIA with Transient Neurological Disturbance (435.9) E1 Neoplasm - Primary Unknown (199.1) El Vision Changes
(368.9) U Spinal Stenosis Unspecified Site (724.00) El Weakness-Rlght / Left / Both (780.9) ABNORMAL PREVIOUS
TESTS
DIAGNOSES (nor -nuuz our) U Abscess (3240) E1 Abnormal X-ray (793.9) El Intracranial Hemorrhage (432.9) D
Sea“ (7964) D Neoplasm - Specify Primary
El Neoplasm - Primary Unknown (199.1)
E] Hemorrhage (4324) Clinical information for Radiologist
[1 stroke (436) (In addition to sign & symptoms check ofl box) Why do you want this exam?
SIGNS AND SYMPTOMS 1 SI El Swelling Head and Neck (784.2)
El Hematoma Face (920) Date of Injury
KNQWN DIAGNOSES our)
E1 Facial Fracture (802.8) Date of Injury E1 Neoplasm - Specify Primary '9 ** El Neoplasm - Primary Unknown
(199.1) E] sin ‘(is Acute (4619) RADIOLOGIST USE ONLY Chronic (473.9) I ABNORMAL PREVIOUS TESTS